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\begin{document}

\title{Subdural Empyema -A Rare Complication of Chronic Otitis Media: A Case
Report}



\author[1]{Emnet Tekeste}%
\author[2]{Genet Tekeste}%
\author[3]{Nahom Daniel}%
\author[4]{Samuel Tekle Mengistu}%
\affil[1]{Barentu Military Hospital, Barentu, Eritrea}%
\affil[2]{Orotta National Referral Hospital, Asmara, Eritrea}%
\affil[3]{General practitioner, Mendefera Zonal Referral Hospital, Medefera, Eritrea}%
\affil[4]{Nakfa Hospital}%


\vspace{-1em}



  
  \date{May 25, 2024}


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Subdural Empyema -A Rare Complication of Chronic Otitis Media: A Case
Report

Emnet Tekeste\textsuperscript{1*+}, Genet Tekeste\textsuperscript{2+},
Nahom Daniel\textsuperscript{3}, Samuel Tekle
Mengistu\textsuperscript{4}

1. General practitioner, Barentu Military Hospital, Barentu, Eritrea,
Email: emenettekeste7@gmail.com, ORCID:
https://orcid.org/0000-0002-8820-8564

2. Surgical resident, Orotta National Referral Hospital, Asmara,
Eritrea, Email: ORCID:

, 3. General practitioner, Mendefera Zonal Referral Hospital, Medefera,
Eritrea, Email: millionweldu1241@yahoo.com

4. Nakfa Hospital, Ministry of Health Northern Red Sea branch, Nakfa,
Eritrea. Email: teklesam7@gmail.com ORCID:
https://orcid.org/0000-0002-2817-1421

*Correspondence: Emnet Tekeste MD, General practitioner, Barentu
Military Hospital, Barentu, Eritrea. Tel +291-1-7205051, Email
emnettekeste7@gmail.com

If any equal contribution of authors that you want to acknowledge

+: These authors contributed equally to this work

\emph{}

\emph{Abstract}

\textbf{Background:} Subdural empyema is an extremely rare and fatal
intracranial complication of chronic otitis media. Due to its rarity and
vague symptoms it is often diagnosed late if not completely missed;
specially in developing countries where the diagnostic modalities are
hardly available or accessible. To the best knowledge of the authors,
this is a preliminary reported case of a subdural empyema as a
complication of chronic otitis media in Eritrea, aiming to inform on the
clinical presentation, preferred diagnostic modalities, and the proper
management of such cases.

\textbf{Case Report:} An eight years old female patient presented with
fever, right ear purulent discharge, right post-auricular swelling, and
altered mental status of two weeks duration. Prior to her admission, she
had history of recurrent purulent discharge from her right ear for
almost 2 years, and had been diagnosed with chronic otitis media. Upon
admission her GCS was 13/15 which later on deteriorated to be 3/15 on
day three. MRI was done which showed a right fronto-tempo-parietal
subdural empyema with mass effect, shifting the midline to the left. She
was immediately started on broad spectrum antibiotics empirically. After
the diagnosis was made, craniotomy was done, and 30ml of pus was removed
from the subdural space. Culture and sensitivity of the pus obtained
intraoperatively was done but produced no yield. Hence, she was
continued on the empirically started antibiotics. The patient's
condition was well improved by post-operative day 4.

\textbf{Conclusion:} It is important to have a high index of suspicion
of intracranial complications in patients with history of chronic otitis
media or other otologic symptoms, and neurologic manifestations.
Subdural empyema still being uncommon even among the intracranial
complications of COM, it is often missed. Hence, timely diagnosis with
MRI, immediate surgical evacuation of the empyema with the prolonged
administration of broad spectrum antibiotics is suggested.

\textbf{Key words:} Subdural empyema, chronic otitis media, Eritrea

\emph{Introduction}

Otitis media is a disease of the middle ear marked by the inflammation
of the mucosal lining. When it lasts more than two weeks, it develops
into chronic otitis media (COM). Chronic otitis media is marked by the
presence of a perforated tympanic membrane, and recurrent purulent
discharge.\textsuperscript{1-3} Otitis media is one of the most common
infections of childhood: by the age of 3 years more than 80\% of
children will have had at least 1 episode of otitis
media.\textsuperscript{4} COM can lead to both extracranial, and
intracranial complications. Sixty to seventy percent of these
complications occur in children and young adults: during the first two
decades of life.\textsuperscript{5-7} Intracranial complication is an
infrequent complication with reported rates ranging from 0.3\% in
developed countries to 3\% in developing
countries.\textsuperscript{5,6}Its pathogenesis, that is its spread from
the ear canal, is through direct invasion of the bone, thrombophlebitis,
haematogenous spread, and dissemination through congenital or traumatic
bone defects.\textsuperscript{6,8,9}

The most common intracranial complications are brain abscess,
meningitis, and lateral sinus
thrombosis.\textsuperscript{3,6,10}Subdural empyema, the purulent
collection between the dura and arachnoid matter, is a rare but serious
intracranial complications of COM.\textsuperscript{8,11} It is
exceedingly rare that a study by Dongol et al. found only one case of
subdural empyema (3.7\%) out of 27 patients of chronic otitis media with
intracranial complications.\textsuperscript{7} Extension from otogenic
infections is the most common cause of subdural empyema in older
children.\textsuperscript{8,9,12} The most common pathogens
are\emph{Streptococcus pneumoniae} (most common), \emph{Haemophilus
influenzae, Moraxella catarrhalis, Staphylococcus aureus} and
Gram-negative rods (\emph{Pseudomonas aeruginosa, Escherichia coli,
Proteus, Klebsiella} ) as well as anaerobic Bacteroides
species.\textsuperscript{5,13,14} Patients with Subdural empyema present
with fever, headache, vomiting, and altered mental
status.\textsuperscript{11,14-16} MRI and CT scan are important in the
diagnosis of subdural empyema; MRI being the most
sensitive.\textsuperscript{6,8,12} Culture and sensitivity from the pus
is necessary although the yield is low.\textsuperscript{14,5-8} The
principles of treatment, common to all intracranial complications,
include early definitive diagnosis, appropriate systemic antibiotic
therapy, neurosurgical intervention, and treatment of the ear lesion
after the patient stabilizes.

\emph{Case Presentation}

An 8 years old female patient presented with the complaint of right ear
purulent discharge and right post auricular swelling of two weeks and
intermittent high grade fever and altered mental status of 3 days
duration prior to admission. She had history of recurrent purulent
discharge from right ear for almost 2 years. Consequently, her parents
brought her to pediatric hospital and was referred to the ENT
department. She was diagnosed chronic otitis media for which she was
given amoxicillin syrup for 7 days and was told to return after 3 months
for surgery.

On physical examination, she was confused with a GCS of 13/15. She was
tachycardic and febrile otherwise the other vital signs were within the
normal range. She had purulent foul smelling discharge from the right
ear. There was a 3cm by 4cm swelling in the postauricular area which was
erythematous and a 0.5cm by 0.4 cm opening with a serosanguinous
discharge over the most fluctuant part of the swelling. She was admitted
to the Pediatric ICU with the diagnosis of right ear chronic suppurative
otitis media, acute mastoiditis, and right post-auricular subperiostial
abscess. She was started on empiric antibiotics: metronidazole (7.5mg/Kg
IV q8hrs) and ceftriaxone (50mg/Kg IV q12hrs). Five hours following her
admission, her GCS lowered to 10/15 and 12 hours later to 6/15. Thus a
diagnosis of brain abscess was entertained. On the
3\textsuperscript{rd}day of her admission, her GCS was 3/15 and her
right pupil was dilated and nonreactive to light while the left was
midway dilated with sluggish reaction to light. Full blood count was
done and revealed Hgb of 6g/dL, WBC-22.3x10\textsuperscript{3} /micL and
80.8\% Neutrophils. She was transfused with 2 units of blood (PRBC). Up
on her admission to the Pediatric ICU, despite the patient's altered
level of consciousness, lumbar puncture was decided to be necessary.
Even though, the patient had altered level of consciousness, she had
none of the lateralizing signs (no signs of focal neurological deficit)
nor did she have any of the Cushing's triad (an increased systolic blood
pressure, bradycardia, and an abnormal respiratory pattern) that
indicate the possibility of an increased intracranial pressure. And
during her arrival, MRI/CT scan could not be done nor were there any
other ways the intracranial pressure could be measured. Moreover, as the
patient had nuchal rigidity during admission along with the altered
mental status, meningoencephalitis was one of the top differentials.
These were the reasons LP had to be done in the presence of altered
level of consciousness, before the patient was started on any
antibiotics. CSF analysis was normal with no blood cells or organisms
present under microscopic analysis, a glucose level of 65mg/dL and a
total protein level of 0.2g/L. Culture of the pus taken from the right
ear and the right postauricular area had no growth; thus she continued
her treatment with Metronidazole and Ceftriaxone. MRI was done on day
three of her admission and showed right fronto-tempo-parietal subdural
empyema with mass effect, effacing the adjacent cortical sulci and
compressing the right lateral ventricle, shifting the midline to the
left. On the neurosurgical team were consulted and they decided to do an
emergency craniotomy. In the OR an estimated amount of 30ml of pus was
removed from the subdural space. Incision and drainage of the post
auricular subperiostial abscess was also done intraoperatively.
Vancomycin (15mg/Kg IV q6hrs) and Chloramphenicol ear drops were added
to her antibiotic regimen for 14 days. Preoperatively she was also given
mannitol to lower the intracranial pressure until the surgical
intervention was done. The patient showed marked improvement
post-operatively. She became fully conscious with GCS 15/15 and was
communicating well by post-op day 4.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 1.} MRI images of the patient showing right
fronto-temporal-parietal subdural empyema (yellow arrow) effacing the
adjacent cortical sulci and compressing the right lateral ventricle,
midline shift to the left (red arrow).

\emph{Discussion}

Subdural empyema is a rare and fatal intracranial complication of
chronic otitis media with a mortality rate of 12.2\% to
28\%.\textsuperscript{11,17} The predisposing risk factors include
neglected middle ear infections, lack of access to health care and
availability of imaging modalities such as CT scan and/or MRI,
immunosuppression, and poor economic
status.\textsuperscript{7,10,18,19}Over the past years, the incidence of
complications of otitis media have decreased with the use of
antibiotics, improved imaging studies, the introduction of the
pneumococcal vaccine, and multidisciplinary
management.\textsuperscript{6,7}

\textbf{Clinical presentation} : The symptoms and signs in patients with
subdural empyema are due to pus collection and the mass effect on the
brain. The classical triad of presentation which include headache, fever
and vomiting is present only in 36\% to 50\% of the patients. Showing
that the triad is not very sensitive in diagnosing subdural abscess. To
emphasise this fact, as was already mentioned above in the case study,
the patient had only fever from the so called `classic triad'.
Therefore, it is generally agreed that the symptom complex of fever,
headache, vomiting, and altered mental status is rather more
precise.\textsuperscript{8,16,20} Even with this, due to the rarity of
the condition, the diagnosis is often delayed if not missed. Therefore,
physicians need to have a high index of suspicion in patients who have
history of COM.

\textbf{Investigation} : Radio-imaging using CT scan or MRI is required
to confirm the diagnosis. In the early stages of the disease however, CT
scan can be normal in 63\% of the cases.\textsuperscript{8} As MRI can
identify intracranial edema better than CT scan, it is more preferable
to use MRI for earlier diagnosis of intracranial
complication.\textsuperscript{6} Similarly MRI is better in recognizing
the extension of the empyema into the interhemispheric fissure and the
posterior fossa.\textsuperscript{14} Hence, in suspected cases of
intracranial subdural empyema for accurate diagnosis MRI is the gold
standard with a sensitivity of 93\%.\textsuperscript{8,12} Laboratory
analysis of blood shows elevated WBC, ESR, and C-reactive
protein.\textsuperscript{6} Culture and sensitivity of intraoperative
pus should be done, even though often empyema is sterile and has no
yield in 50\% of the cases.\textsuperscript{6,8,16} It was similar in
our case. This is due to the administration of antibiotics before the
diagnosis is made.

\textbf{Management} : The mainstay treatment of subdural empyema
includes the use of antibiotics and surgical evacuation of the pus.
There should be immediate initiation of broad spectrum antibiotics. A
combination of oxacillin/nafcillin, a third-generation cephalosporin and
metronidazole covers the most common pathogens. Due to the increasing
presence of penicillin resistant \emph{Streptococcus pneumoniae}
and\emph{Staphylococcus aureus} the use of vancomycin instead of
oxacillin is preferred.\textsuperscript{6,8,15,16,21} This was done in
our case and the outcome was satisfactory. Most recommend a minimum 2
weeks of IV antibiotics while others suggest continuation for 6 weeks.
In our case, the two weeks of IV antibiotics were found to be adequate.
But almost all agree that IV antibiotics must be followed by 6 weeks of
oral antibiotics.\textsuperscript{6,8,15,22}

Surgical drainage of the subdural pus is the next crucial step following
the initiation of antibiotics. The surgical procedure can either be
craniotomy or burr whole. Craniotomy is preferred as it allows adequate
exploration; complete removal of pus, loculations, and the possible
calcifications on the abscess wall, and effective decompression of
increased intracranial pressure.\textsuperscript{8,11,14,16} Moreover,
recurrence of subdural empyema is more common in Burr hole (almost 40\%)
as compared to craniotomy.\textsuperscript{15,16,20} However, in the
weak patients or those in septic shock or when the empyema is
parafalcine, Burr hole is the preferred procedure. The surgical
intervention should be done as soon as possible, since any delay results
in worsening of outcome. Disability reaches as high as 70\% in those who
were operated after 72 hours of presentation as compared to the 10\% in
those who were operated within 72 hours.\textsuperscript{11,15,17}

Administration of prophylactic anticonvulsants is advised as seizures
occur in 32\% to 44\% of patients with subdural
empyema.\textsuperscript{15,16,20} Moreover mannitol should be given
preoperatively and postoperatively to reduce the increased intracranial
pressure.\textsuperscript{6,15,21} After the patient stabilizes the
chronic otitis media and mastoiditis should be properly treated by the
ENT specialists.\textsuperscript{3,6,10} Similarly our patient was later
on transferred to the ENT department where her chronic otitis media was
properly addressed.

Factors such as age of the patient, delay in presentation, extent of the
sepsis, and the subdural empyema along with level of consciousness at
presentation significantly affect the outcome of the
patient.\textsuperscript{16} Morbidities such as sensorineural hearing
loss, residual neurological deficits including seizures and hemiparesis
are seen in about 28\% of the survivors.\textsuperscript{3,11} Therefore
to achieve good results early diagnosis, immediate surgical
intervention, and appropriate antibiotic therapy are of paramount
importance.

\emph{Conclusion}

Patients with a positive history of chronic otitis media or any otologic
complaints such as otorrhea who present with fever, headache, vomiting
and altered level of consciousness should trigger a high index of
suspicion for subdural empyema. MRI is the gold standard in confirming
the diagnosis. Early diagnosis and timely surgical intervention, and
appropriate antibiotic therapy are of utmost significance in the
management of subdural empyema following chronic otitis media.

\emph{Conflict of interest}

No conflicts of interest were declared by the authors.

\emph{Financial support and sponsorship}

This report received no specific grant from any funding agency in the
hospital, public, commercial, or other sectors.

\emph{Consent for Publication}

Written informed consent was acquired from the patient for publication
of this report and associated images. A copy of written consent is
available for review by the Editor-in-Chief of this journal.

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